FORMULIR PENDAFTARAN CALON PPDB RA AL-WAHYU

TAHUN PELAJARAN 2024-2025

IDENTITAS PESERTA DIDIK

NAMA LENGKAP
: ...............................................................................................................................
NAMA PANGGILAN
: ...............................................................................................................................
JENIS KELAMIN
: ...............................................................................................................................
NIK : ..............................................................................................................................
.
TTL : ..............................................................................................................................
.
AGAMA : ..............................................................................................................................
.
ALAMAT LENGKAP
: ...............................................................................................................................
..............................................................................................................................
.
ANAK KE
: ...............................................................................................................................
JUMLAH SAUDARA
: ...............................................................................................................................
TINGGAL BERSAMA
: ...............................................................................................................................
USIA : ..............................................................................................................................
.
NO. KK
: ...............................................................................................................................
KEPALA DI KK
: ...............................................................................................................................
NO. HP
: ...............................................................................................................................
UKURAN BAJU : S/ M/ L/ XL/ JUMBO

IDENTITAS AYAH KANDUNG (SESUSAI AKTA ANAK DAN KK)

NAMA LENGKAP
: ...............................................................................................................................
NIK : ..............................................................................................................................
.
STATUS : A. MASIH HIDUP B. MENINGGAL
TTL : ..............................................................................................................................
.
PENDIDIKAN AKHIR
: ...............................................................................................................................
PEKERJAAN : ..............................................................................................................................
.
PENGHASILAN/BLN : A. < 500.000 B. 500.000-1.000.000 C. 1.100.000-2.000.000 D. > 2.000.000
NO. HP
: ...............................................................................................................................
STATUS RUMAH : A. ORANGTUA B. MILIK SENDIRI C. KONTRAK
ALAMAT LENGKAP
: ...............................................................................................................................
..............................................................................................................................
.
IDENTITAS IBU KANDUNG (SESUAI AKTA ANAK DAN KK)

NAMA LENGKAP
: ...............................................................................................................................
NIK : ..............................................................................................................................
.
STATUS : A. MASIH HIDUP B. MENINGGAL
TTL : ..............................................................................................................................
.
PENDIDIKAN AKHIR
: ...............................................................................................................................
PEKERJAAN : ..............................................................................................................................
.
PENGHASILAN/BLN : A. < 500.000 B. 500.000-1.000.000 C. 1.100.000-2.000.000 D. > 2.000.000
NO. HP
: ...............................................................................................................................
STATUS RUMAH : A. ORANGTUA B. MILIK SENDIRI C. KONTRAK
ALAMAT LENGKAP
: ...............................................................................................................................
..............................................................................................................................
.

IDENTITAS WALI SANTRI (TIDAK USAH DIISI JIKA SAMA DENGAN AYAH /IBU KANDUNG)

NAMA LENGKAP
: ...............................................................................................................................
NIK : ..............................................................................................................................
.
STATUS : A. MASIH HIDUP B. MENINGGAL
TTL : ..............................................................................................................................
.
PENDIDIKAN AKHIR
: ...............................................................................................................................
PEKERJAAN : ..............................................................................................................................
.
PENGHASILAN/BLN : A. < 500.000 B. 500.000-1.000.000 C. 1.100.000-2.000.000 D. > 2.000.000
STATUS RUMAH : A. ORANGTUA B. MILIK SENDIRI C. KONTRAK
ALAMAT LENGKAP
: ...............................................................................................................................
..............................................................................................................................
.
NO. HP
: ...............................................................................................................................

APA ALASAN BAPAK/IBU MENITIPKAN ANANDA DI RA AL WAHYU ?

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APA HARAPAN BAPAK/IBU TERHADAP ANANDA ?

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KESANGGUPAN ORANG TUA TERHADAP PENDAMPINGAN PERKEMBANGAN 6 ASPEK ANANDA

Apakah Bapak/Ibu sanggup mendampingi ananda belajar di rumah?
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Apakah Bapak/Ibu sanggup mengajak ananda sholat wajib 5 waktu ?
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Berapakah infaq yang akan diberikan oleh ayah/bunda ke madrasah setiap bulannya ?
A. 60.000 B. 50.000
Apa pesan Bapak/Ibu untuk ustadzah yang akan mendampingi ananda belajar di madarasah Al-
Wahyu?
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Mojokerto, ......................................
Orang Tua/ Wali Santri

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